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1 ASSOCIATION FEBRUARY 15, 1964 * VOL. 90, NO. 7 Detection of Pericardial Effusion by Radioisotope Heart Scanning LEONARD ROSENTHALI M.S., M.D., Montreal THERE are a number of methods to detect the presence of pericardial effusion with various degrees of accuracy. Electrocardiography and fluoroscopy may suggest the presence of an effusion, but these methods are not always conclusive. A diagnostic pericardial tap is generally not advisable. Pericardial fluid surrounds the heart inferiorly, anteriorly and laterally. Steinberg, von Gal and Finby5 were able to demonstrate this distribution as an increased soft tissue thickening in the intravenous angiocardiogram. Stauffer et ak' injected via venepuncture pure carbon dioxide gas which is trapped in the right atrium when the patient is in the left lateral decubitus position. A right atrial wall thickness exceeding 4 mm. is suggestive of pericardial reaction. Radioisotope heart scanning by an automatic scintillation scanner can employ any radioactive agent which remains in the circulation long enough to permit the cardiac blood pooi to be visualized. A significant discrepancy in size between the cardiac blood pool and the heart silhouette of the chest roentgenogram implies myocardial hypertrophy, pericardial thickening and/or effusion. The commonly used test agent is radioiodinated human serum albumin (1131-HSA); its application to the detection of large vascular pools was established by Rejali, Maclntyre and Friedell.8 When pulmonary disease and/or pleural effusion overlaps the heart, it may be difficult to outline the cardiac silhouette for comparison with the blood pool. Since fluid accumulates in the inferior portion of the pericardial sac, the distance between the liver and the heart is increased. To appreciate this, colloidal radiogold (Au198) is added to the I131. HSA. Colloidal Au198 is picked up predominantly by the Kupifer cells and this outlines the liver. Thus the relation of the liver margin to the cardiac blood pool can be determined. The following report describes the successful use of this method. From the Department of Radiology, The Montreal General Hospital. 447 ABSTRACT A marked difference between the cardiac silhouette on the six-foot chest roentgenogram and the cardiac blood pool, determined by radioisotope scanning, has been shown to be consistent with pericardial effusion and/or thickening. It has also been observed that the cardiac blood pool is separated from the liver margin by the interposition of pericardial fluid and/or thickening. This separation was not demonstrated in the presence of a normal pencardium. To appreciate these features, 400.c. of radioiodinated human serum albumin and 50.c. of colloidal radiogold were used for scanning. The former outlined the blood pool and the latter demonstrated the position of the liver.

2 448 ROSENTHALL: PERICARDIAL EEPusIoN Canad. Med. Ass. 3. Feb , vol. 90 Fig. I.-(Case 1) Left-Supine roentgenogram showing large globular heart. Right-Heart scan demonstrating separation between cardiac blood pool and liver margin. Marked discrepancy in transverse diameters between the cardiac blood pool and cardiac silhouette. CASE REPORTS CASE 1.-This 59-year-old woman was given a therapeutic dose of radioactive iodine two years previously as a treatment for intractable angina. Serial chest radiographs revealed a progressively enlarging heart. Electrocardiographic changes were non-specific and could be related to ischemia or digitalis. There was no clinical evidence of jugular distension. A cardiac scan revealed a 3-cm. separation between the cardiac blood pool and liver margin, and a difference of 12 cm. between the transverse diameter of the cardiac blood pool and the cardiac silhouette on the supine chest roentgenogram. Fluid was obtained at pericardiocentesis (see Fig. 1). CAsE 2.-This 32-year-old Eskimo was admitted with abdominal distension, dyspnea and swelling of the lower extremities. The blood pressure was 90/70 mm. Hg; the pulse, 100 and regular. Jugular venous distension to the angles of the jaw and hepatojugular refiux were present. Electrocardiography revealed changes compatible with pericarditis. The chest roentgenogram showed bilateral pleural effusion and at fluoroscopy there was a marked decrease in the amplitude of the cardiac pulsations. A heart scan was performed preoperatively (Fig. 2a); this demonstrated a significant discrepancy between the transverse diameters of the cardiac blood pool and the cardiac silhouette, and a 5-cm. separation between the cardiac blood pool and Fig. 2a.-(Case 2) Left-Preoperative supine chest radiograph demonstrating slightly enlarged heart with bilateral loculated pleural effusion. Right-Preoperative heart scan showing a significant discrepancy between the transverse diameters of the cardiac blood pool and cardiac silhouette. There is a 5-cm. separation between the cardiac blood pool and liver margin. Note the vascular congestion above the base of the heart.

3 Canad. Med. Ass. 3. Feb. 15, 1964, vol. 90 ROSENTHALL: Pi.mcA1uIAL EFFUSION 449 Fig. 2b.-(Case 2) Left-Chest roentgenogram following pericardiectomy. Slight decrease in heart size. Right-Heart scan following pericardlectomy reveals re-expansion of the cardiac blood pool. There is no longer a separation between the cardiac blood pool and hepatic margin. the liver margin. In fact, the transverse diameter of the mediastinal blood pool was greater than the cardiac blood pooi, indicating congestion. At operation, the outer layer of the pericardium was about 1 cm. thick, completely surrounding the heart. Within this outer dense fibrous layer there was about 300 ml. of darkly blood-tinged fluid compressing the heart. Fig. 2b is a postpericardiectomy heart scan demonstrating reexpansion of the cardiac blood pool and disappearance of the separation between the blood pool and liver margin. CAsE 3.-This 49-year-old man had acyanotic congenital heart disease. There was no evidence of jugular venous distension or hepatojugular reflux. The heart scan demonstrated dilatation of the cardiac chambers but no significant pericardial effusion. (Note, in Fig. 3, the lack of separation between the liver margin and cardiac blood pool, and the insignfficant discrepancy between the transverse diameters of the cardiac blood pool and cardiac silhouette.) V Fig. 3.-(Case 3) Left-Supine chest roentgenogram demonstrating cardiomegaly in a patient known to have acyanotic congenital heart disease. Right-Heart scan. The dilated cardiac chambers are reflected in the enlarged cardiac bleod pool. There Is no significant difference in the transverse diameters of the cardiac blood pool and the cardiac silhouette, nor is there a separation between the cardiac blood pool and liver margin.

4 450 ROSENTHALL: PFaUcA1UIAL EFFUSION Canad. Med. Ass. J. Feb. 15, 1964, vol. 90 Fig. 4.-(Case 4) Left-Supine chest roentgenogram demonstrating cardiomegaly In a patient who has chronic renal failure. Right-Heart scan showing a significant difference between the transverse diameters of the cardiac blood pool and heart silhouette. There is separation between the cardiac blood pool and liver margin. CAsE 4.-This 19-year-old man with chronic glomerulonephritis and renal failure had been on continuous dialysis for one year. Chest roentgenograms showed an increasing cardiac silhouette. Electrocardiographic changes were non-specific and there was no evidence of jugular venous distension or hepatojugular reflux. A precordial friction rub was heard. A heart scan demonstrated a separation between the cardiac blood pool and liver margin of 1 cm., and a 10-cm. discrepancy between the transverse diameter of the cardiac blood pool and heart silhouette. A pericardiocentesis removed only 3 ml. of straw-coloured fluid. At autopsy the left ventricular myocardium was unusually thickened to 3 cm. (see Fig. 4). CASE 5.-This 45-year-old woman had an ovarian carcinoma and massive right pleural effusion obscuring the right border of the heart. The cardiac scan revealed a normal-sized blood pool with no separation between it and the liver margin. This was interpreted as presenting no evidence of significant pericardial fluid. The electrocardiogram and clinical signs and symptoms gave no evidence of pericarditis. Aspiration of the right pleural fluid revealed a normal-sized cardiac silhouette, thus confirming the impression gained from the heart scan (see Fig. 5). Fig. 5.-(Case 5) Left-Supine chest roentgenogram demonstrating massive right pleural effusion which is obscuring the right heart border. Right-No separation between the cardiac blood pool and hepatic margin despite the presence of a large amount of fluid.

5 Canad. Med. Ass..* Ros.'raAn.: PERICARDIAL EFFUSION 451 Feb. 15, vol. 90 DISCUSSION Of the 80 heart scans performed by the method described, only one false positive was found among those patients who came to operation or underwent angiocardiography, pericardiocentesis or necropsy. This was in a patient with an unusually thickened myocardium (Case 4, Fig. 4). Some of the patients had signs and symptoms referable to a pericardial effusion; others were asymptomatic save for a large heart. The clear zone between the cardiac blood pool and liver margin has always been demonstrated, including situations wherein the cardiac outline was obscured by overlapping lung changes and/or pleural effusion. In patients with massive unilateral or bilateral effusions, but normal pericardium, the clear zone did not appear (Case 5, Fig. 5). The separation between the cardiac blood pool and liver margin may also be demonstrated by using radioiodinated iodipamide (I'31-Cholografin) *1, 2 This procedure has the added advantage of delivering a lower radiation dose to the patient. However, the heart scans performed in our institution are relatively few in number; such procedures are carried out at irregular intervals, and colloidal Au198 and 1131-HSA are always on hand-the former for liver scans and function studies, the latter for blood volumes. The smallest detectable volume of pericardial fluid has not been ascertained in the present series. In an experimental system consisting of a pair of concentric balloons immersed in a phantom, Bonte et al.' were readily able to detect the presence of about 300 ml. of pericardial fluid in the equivalent of a subject with a normal-sized heart. The advantages of the isotopic method are as follows: (1) It is a relatively rapid and innocuous procedure. (2) It is free of the usual hazards of catheterization and iodinated contrast materials. (3) Save for the intravenous injection of the isotope, the technique is carried out completely by a technician. SUMMARY A review of 80 heart scans is presented using a combination of colloidal Au198 and 1131-HSA for the detection of pericardial effusion and/or pericardial thickening. As yet no proved symptomatic pericardial effusions have been missed by this procedure, and a number of asymptomatic effusions have been detected, the presence of which was later confirmed. The advantages of this technique are its freedom from the usual hazards of catheterization and iodinated opaque media, the fact that it is a relatively rapid and innocuous procedure, and that it can be carried out almost completely by a technician. The author wishes to acknowledge the technical assistance rendered by Cecile Basque, Joan Macaulay and Barbara Sach. REFERENCES 1. BONTE, F. J. et al.: Southern Med..7., 55: 577, MACINTYRE, W. J., CRESPO, G. 0. AND CHRISTIE, J. H.: Amer. J. Roentgen., 89: 315, REJ-ILI, A. M., MACINTYRE, W. J. AND FRIEDELL, H. I.: Ibid., 79: STAUFFER, H. M. et al.:.7. A. M. A., 172: 1122, STEINBERG, I., VON GAL, H. V. AND FINBY, N.: Amer. J. Roentgen., 79: 321, PAGES OUT OF THE PAST: PUERPERAL SEPSIS The diagnosis of puerperal infection, as a rule, is not difficult, but the determination of the variety of the infection, and the course it will pursue is frequently attended with insurmountable difficulties. Bacterio ogical examinations of the lochia and of the blood do not afford us the aid in diagnosis which many claim for them. Bacteriologists surround themselves with too many casuistic refinements to be of much help to the clinician at the bedside. They lay so much stress upon the haemolytic and non-haemolytic properties of the streptococci, and in the same breath they tell us the non-haemolytic variety may become haemolytic, and vice versa. Further, they tell us, and we know it to be so, streptococci are found in the gravid and puerperal woman, without any pathological significance. Hence, a woman in child-birth with fever due to other causes, might have her condition erroneously diagnosed as puerperal infection, because streptococci were found in the lochia. Still we would not wish to be understood as totally disregarding the value of bacteriology in the diagnosis and prognosis of puerperal septic infection. A given case must be subjected to the most careful clinical scrutiny and then, in cases of doubt, bacteriological examination of the discharges and of the blood may be of some value in diagnosis and prognosis. He who would detect an infection at the onset, would see to it that every puerperal woman had the temperature taken per rectum, at least twice daily. In the presence of a temperature above the normal, he should not throw dust into his own eyes no matter what he would do to the eyes of others by attributing it to nervousness, indigestion, malaria, and milk fever. Before an audience FROM THE JOURNAL OF FIFTY YEARS AGO like the present, it is superfluous to state that the flow of milk into the breasts is not attended with fever. Malaria at the present day, need not be guessed at. It can be excluded or established by the absence or presence of the plasmodia. Fever therefore, in the puerperal woman is prima facie evidence of puerperal infection. But the evidence requires to be thoroughly sifted; many cases will show a temperature of two or more degrees above the normal, for one or two days, during the first week constitutin. the group the Germans have termed "one-day fever cases'. Zweifel, we think has detected the etiological factor in these cases, in the presence of the blood clots that accumulate in the cervix at the termination of the third stage of labour. Be this as it may, ever since we have adopted his suggestion of manually removing all the blood from the cervix at the end of labour, we have seen fewer of the so-called cases of one-day fever. Constipation is frequently held as a cause of fever in the puerperium, and every one of us has seen the temperature suddenly shoot up to 1050 or 1060, and as suddenly drop to the normal after a thorough emptying of the bowels. To our mind, the constipation acts only in an indirect way, by the faecal mass accumulated in the rectum forming a direct barrier to the escape of the lochia, either from the cervix, or from the upper jpart of the vaginal canal In what other way could an over oaded bowel ve rise suddenly to such a high temperature which wound disappear as suddenly with the removal of the faecal mass? Here, also, we need not grope in the dark. The insertion of the finger into the vagina will detect the hard bulging posterior wall and the obstruction to the outflow of the normal discharges.- Hiram N. Vineberg, Canad. Med. Ass. 1., 4: 201, 1914.

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